Testosterone and Sexual Function for Men With MS

Testosterone, Multiple Sclerosis, and Sexual Function

Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system characterized by inflammation, demyelination, and progressive neurological disability. MS results in motor, sensory, and cognitive impairments.  In addition, MS significantly affects endocrine function and sexual health. Testosterone is a key sex hormone in both men and women.  Research has demonstrated it as an important biological factor influencing disease activity, neuroprotection, and sexual function in individuals with MS (1). 

Testosterone has demonstrated anti-inflammatory and neuroprotective properties. Experimental and clinical evidence indicates that testosterone can reduce inflammatory cytokine production. It also protects neurons from oxidative stress, partly through androgen receptor–mediated mechanisms (2). 

Additionally, men tend to develop MS less frequently than women but often experience more severe disease progression. This paradox has been partially attributed to differences in sex hormone levels, including age-related declines in testosterone (male menopause or andropause), which may exacerbate disease activity.

Sexual Dysfunction in Men with Multiple Sclerosis

Sexual dysfunction is a common but often underreported symptom of MS. It affects both men and women and can significantly reduce quality of life. A recent meta-analysis of 29 studies of 3,349 men with MS found a pooled SD prevalence of 66%, demonstrating much higher levels of significant SD in men with MS than in the general population (3).  SD in MS has been found to negatively impact quality of life (4). 

Sexual dysfunction in MS is typically categorized into three types (5): 

1. Primary dysfunction – directly caused by neurological damage (e.g., erectile dysfunction, decreased genital sensation). 
2. Secondary dysfunction – resulting from MS symptoms such as fatigue, spasticity, or bladder dysfunction.
3. Tertiary dysfunction – related to psychological and social factors, including depression and reduced self-esteem.

Role of Testosterone in Sexual Function

Testosterone plays a central role in sexual desire (libido), arousal, and overall sexual performance in both sexes. In men, low testosterone is strongly associated with decreased libido, erectile dysfunction, and reduced sexual satisfaction. In women, testosterone also contributes to sexual desire and arousal, though its role is less pronounced than in men. 

In the context of MS, testosterone deficiency may exacerbate sexual dysfunction through multiple mechanisms: 

• Reduced libido due to testosterone insufficiency
• Erectile dysfunction linked to both neurological damage and hormonal imbalance
• Fatigue and depressed mood, which are influenced by both MS and low testosterone

Given that MS already disrupts neural pathways involved in sexual response, concurrent hormonal deficiencies can compound these effects. 

Interactions Between Testosterone, MS, and Sexual Dysfunction

The relationship between testosterone, MS, and sexual function is complex and multi-directional. MS-related neurological damage can impair sexual function directly, while decreasing testosterone levels may further influence both disease symptoms and sexual health (5). 

Low testosterone levels may worsen some MS symptoms, including fatigue, mood, and cognitive function, which in turn negatively impacts sexual function. Conversely, improving testosterone levels may enhance the aforementioned neurological outcomes and sexual health, although the evidence for this in MS is limited. 

Theoretically, testosterone’s neuroprotective effects could help preserve neural pathways that regulate sexual function.  However, it is important to note that evidence for testosterone therapy in MS remains limited. Most studies are small or preliminary, and large-scale randomized controlled trials are needed to confirm long-term efficacy and safety (6). 

Assessment and Treatment of Sexual Dysfunction in Men with MS

Given the high prevalence of SD in men and impact on quality of life, all persons with MS should receive screening for SD. A reliable and valid 15-item screening test for both men and women with MS that has been translated into over 12 languages is the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15, which can be completed in 3 or 4 minutes (7). 

There is good evidence from multiple studies that found psychoeducation on causes and treatments of SD leads to improved function and satisfaction (8). 

If low testosterone levels are detected, testosterone supplementation to bring levels into the average/high average range may improve aspects of primary sexual dysfunction (libido), secondary sexual dysfunction (energy levels) and tertiary sexual dysfunction (mood, confidence).  However, the evidence is based on clinical observations and pilot studies.  More robust studies need to be conducted. 

There is good evidence that erectile dysfunction in MS can be successfully treated with PDE-5 inhibitors, such as sildenafil, tadalafil, vardenafil, etc.  However, if the neurologic mechanism to initiate an erection is compromised, then injections of vasoactive agents (e.g. alprostadil, papaverine/phentolamine combination, or papaverine/phentolamine/alprostadil mix) directly into the corpus cavernosa have proven to be highly effective.  There is very high patient satisfaction with the injectable meds. 

Secondary symptoms such as fatigue can be managed with energy conservation techniques, sexual positions that are energy conserving, stimulants, and physical therapy.  Tertiary SD symptoms such as MS induced body image or self-esteem issues can be successfully addressed with brief counseling and sex therapy (5,9).

References

References: 

1. Buxhoeveden S, Swift-Scanlan T, Goldman MD, Canissario R, Oh U. Exploring Sex-Based Mechanisms of Inflammation and Neurodegeneration in Multiple Sclerosis. Biol Res Nurs. 2026 Apr;28(2):283-295.  
2. Yang L, Zhou R, Tong Y, Chen P, Shen Y, Miao S, Liu X. Neuroprotection by dihydrotestosterone in LPS-induced neuroinflammation. Neurobiol Dis. 2020 Jul;140:104814.  
3. Shaygannejad V, Mirmosayyeb O, Vaheb S, Nehzat N, Ghajarzadeh M. The prevalence of sexual dysfunction and erectile dysfunction in men with multiple sclerosis: A systematic review and meta-analysis. Neurologia (Engl Ed). 2025 Jan-Feb;40(1):22-31. 
4. Schairer, L., Foley, F.W., Zemon, V., Campagnolo, D., Tyry, T., Marrie, R., Gromisch, E., and Schairer, D.   (2014).  The impact of sexual dysfunction on health-related quality of life in people with multiple sclerosis. Multiple Sclerosis Journal. 20:610-616.
5. Foley, F.W.  (2016).  Assessment and treatment of sexual dysfunction in multiple sclerosis.  In: B. Giesser (Ed.) Primer on multiple sclerosis, 2nd edition. New York:  Oxford University Press
6. Hammad MAM, Rush A, Loeb CA, Banton J, Abou Chawareb E, Khanmammadova N, Gevorkyan RR, Barham DW, Yafi FA, Jenkins LC. Multiple sclerosis and hypogonadism: is there a relationship? Sex Med Rev. 2024 Mar 26;12(2):178-182.
7. Foley, F.W., Zemon, V., Campagnolo, D., Tyry, T., Vollmer, T., Marrie, R., Farrell, E.,  Beier, M.,and Schairer, L.   (2013).  Reliability and validity of the Multiple Sclerosis  Intimacy and Sexuality Scale: Re-validation with a large United States sample.  Multiple Sclerosis Journal, 19(9):1197-1203. 
8. Afshar B, Amini L, Hasani M, Jahanfar S, Massood Nabavi S. The most effective sexual function and dysfunction interventions in individuals with multiple sclerosis: A systematic review and meta-analysis. Int J Reprod Biomed. 2022 May 23;20(4):241-254. doi: 10.18502/ijrm.v20i4.10897. PMID: 35822180; PMCID: PMC9260072.
9. Foley, F.W., LaRocca, N.G., Sorgen, A., & Zemon, V.  (2001).  Rehabilitation of intimacy and sexual dysfunction in couples with multiple sclerosis. Multiple Sclerosis:  Clinical and Laboratory Research., 7 (6): 417-421.